Principalism is a concept made up of four ethical principles that outline the basics of bioethics. These principles include respect for autonomy, nonmaleficence, beneficence, and justice. Respect for autonomy can be described as respect for the decisions made by autonomous persons. Nonmaleficience means doing no harm to others.

Beneficence describes the principles of preventing harm, providing benefits, and doing what is in the best interest of others. Justice describes fair distribution of benefits, risks, and costs (Beauchamp and DeGrazia, 2004).

I would personally rank the four principles as follows:

Nonmaleficence

Beneficence

Autonomy

Justice

I think as a society, we should "first do no harm" and take care of each other as fellow human beings. Secondly, I would rank beneficence, as this principle gives us all an opportunity to do no harm plus to do good for others. Autonomy gives us the freedom to choose what we wish to do and what good we choose to participate in.

Justice ensures all humans are fairly represented and that everyone is a recipient of the beneficence of others. I think the Christian narrative would rank the principles in the order of nonmaleficence, beneficence, justice, and autonomy last. To live as Christ lived would be to put the needs of others before our own.

According to our lecture, principalism in the United States, particularly regarding bioethics, has been critiqued for raising autonomy to the most important principle on the list (Lecture 3, 2015). I can see where this concern is coming from, as American culture tends to get selfish and people forget to balance their needs with the needs of others.

I can think of a personal example from working in the hospital that was most disturbing to me. We had a 23 year old woman on our unit with chronic GI issues that was well known to the entire hospital for being a drug seeker who tried to manipulate providers and exercised control by refusing aspects of her care - gait belts, lab draws, vital signs, you name it. Her refusal of an initial colonoscopy led to multiple infections throughout her hospital stay.

I was frustrated one night because she refused to let me change the dressing on her infected IJ line, and my sentiment echoed that of all the nurses and doctors at the hospital: "what is she doing here if she will not let us help her get better?" I spoke with my nurse manager about this, and while she acknowledged my concerns, we could not force her to do anything she refused - we could only document it.

This patient later overdosed on heroin that her boyfriend brought to the hospital for her and remained in the ICU for months. So yes, according to the principle of autonomy, this patient had a right to make all the decisions that caused her condition to worsen. I think American culture could use a little modification on the importance of autonomy.

Although this woman was competent, her drug addiction heavily influenced her mental capacity. I struggle with the fact that "we could only document her refusal," when she really should have had access to mental health services and addiction counseling. The hospital system could have done better to prevent harm and offer her the services she needed.

Beauchamp, T. L., and DeGrazia, D. (2004). "Principles and principalism" in Philosophy and medicine vol. 78. Handbook of bioethics: Taking stock of the field from a philosophical perspective. Dordrecht: Kluwer Academic Publishers.

Lecture 3. (2015). PHI-413V: Biomedical Ethics in the Christian Narrative. Phoenix, AZ: Grand Canyon University.